Table Of ContentAtlas of
Polysomnography
FFMM..iinndddd ii 88//77//22000099 33::2288::0000 PPMM
FFMM..iinndddd iiii 88//77//22000099 33::2288::0000 PPMM
Atlas of
Polysomnography
SECOND EDITION
James D. Geyer, MD
Director, Sleep Program
Associate Professor of Neurology and Sleep Medicine
Alabama Neurology and Sleep Medicine
Tuscaloosa, Alabama
Paul R. Carney, MD
Wilder Professor and Chief
Division of Pediatric Neurology
Director, Comprehensive Pediatric Epilepsy Program
Departments of Pediatrics and Neurology
McKnight Brain Institute
University of Florida College of Medicine
Gainesville, Florida
Troy A. Payne, MD
Medical Director
St Cloud Hospital Sleep Center
St Cloud, Minnesota
FFMM..iinndddd iiiiii 88//77//22000099 33::2288::0000 PPMM
Acquisitions Editor: Lisa McAllister
Product Manager: Tom Gibbons
Vendor Manager: Alicia Jackson
Senior Manufacturing Manager: Benjamin Rivera
Marketing Manager: Brian Freiland
Design Coordinator: Holly McLaughlin
Production Service: SPi Technologies
” 2010 by Lippincott Williams & Wilkins, a Wolters Kluwer business
530 Walnut Street
Philadelphia, PA 19106 USA
LWW.com
All rights reserved. This book is protected by copyright. No part of this book may be reproduced in any form by any means,
including photocopying, or utilized by any information storage and retrieval system without written permission from the copy-
right owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by
individuals as part of their offi cial duties as U.S. government employees are not covered by the above-mentioned copyright.
Printed in China
Library of Congress Cataloging-in-Publication Data
Atlas of polysomnography / James D. Geyer, Paul R. Carney, Troy Payne.—2nd ed.
p. ; cm.
Rev. ed. of: Atlas of digital polysomnography / James D. Geyer ... [et al.]. c2000.
Includes index.
ISBN-13: 978-1-6054-7228-7
ISBN-10: 1-6054-7228-X
1. Sleep disorders—Atlases. 2. Polysomnography—Atlases. I. Geyer, James D. II. Carney, Paul R. III. Payne, Troy.
IV. Atlas of digital polysomnography.
[DNLM: 1. Sleep—physiology—Atlases. 2. Polysomnography—Atlases. 3. Sleep Disorders—diagnosis—Atlases.
WL 17 A8844 2010]
RC547.A836 2010
616.8’498—dc22
2009028925
Care has been taken to confi rm the accuracy of the information presented and to describe generally accepted practices. However,
the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the
information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy
of the contents of the publication. Application of the information in a particular situation remains the professional responsibil-
ity of the practitioner.
The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text
are in accordance with current recommendations and practice at the time of publication. However, in view of ongoing research,
changes in government regulations, and the constant fl ow of information relating to drug therapy and drug reactions, the reader
is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precau-
tions. This is particularly important when the recommended agent is a new or infrequently employed drug.
Some drugs and medical devices presented in the publication have Food and Drug Administration (FDA) clearance for
limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each
drug or device planned for use in their clinical practice.
To purchase additional copies of this book, call our customer service department at (800) 638—3030 or fax orders to (301)
223—2320. International customers should call (301) 223—2300.
Visit Lippincott Williams & Wilkins on the Internet: at LWW.com. Lippincott Williams & Wilkins customer service representa-
tives are available from 8:30 am to 6 pm, EST.
10 9 8 7 6 5 4 3 2 1
FFMM..iinndddd iivv 88//77//22000099 33::2288::0011 PPMM
To our families
and to the memory of Michael Aldrich
FFMM..iinndddd vv 88//77//22000099 33::2288::0011 PPMM
Contributors
Monica Henderson, RN, RPSGT Sachin Talathi, PhD
Sleep Health Coordinator J. Crayton Pruitt Family Department of Biomedical
Department of Sleep Medicine Engineering
Alabama Neurology and Sleep Medicine University of Florida McKnight Brain Institute
Tuscaloosa, Alabama Gainesville, Florida
Jennifer Parr, RPSGT Julie Tsikhlakis, RN, BSN
Chief Sleep Technician Sleep Health Coordinator
DCH Sleep Center Department of Sleep Medicine
DCH Health System Alabama Neurology and Sleep Medicine
Northport, Alabama Tuscaloosa, Alabama
Betty Seals, REEGT
Director
DCH Sleep Center
DCH Health System
Tuscaloosa, Alabama
vi
FFMM..iinndddd vvii 88//77//22000099 33::2288::0011 PPMM
Preface to the Second Edition
Sleep medicine continues to evolve rapidly as a subspecialty 20 Hz may be suffi cient; for rapidly varying signals, such as
with numerous disorders now recognized and an ever-c hanging EEG and EMG, the sampling rate must be much higher, usually
set of diagnostic criteria and protocols. As with any medical 250 Hz or more. If the sampling rate is inadequate, waveforms
discipline, accurate diagnosis is an essential prerequisite for are distorted and scoring and interpretation may be erroneous.
a rational approach to management. Polysomnography, the For example, if the sampling rate for eye movement channels is
recording of multiple physiologic functions during sleep, was too low, the sharp defl ection associated with a rapid eye move-
developed in the 1970s and is the most important laboratory ment may appear as a slower defl ection characteristic of a slow
test used in sleep medicine. Polysomnography complements eye movement.
the clinical evaluation and assists with diagnosis and manage- Because of the differences in signal acquisition and display
ment of a variety of sleep disorders.1 parameters, not all digital recordings have the same appear-
Digital amplifi ers and computerized signal processing are ance. In addition, although transducers used for the recording
now the standard of care and provide many advantages over of EEG, EOG, and EMG are largely standardized, EEG and EOG
older analog amplifi ers and paper recording. This is especially montages vary among laboratories. Furthermore, transducers
true for the evaluation of brief electroencephalographic (EEG) and recording techniques for the assessment of respiration dur-
transients such as epileptiform sharp waves and spikes and their ing sleep vary widely among sleep laboratories.2 For example,
differentiation from artifacts and benign EEG waveforms. This airfl ow can be monitored directly with a pneumotachograph,
section of the book has been signifi cantly expanded. Digitized thermistor, or thermocouple or indirectly with the recordings
data can also be displayed using a variety of montages depend- of tracheal sound or by the summation of signals from tho-
ing on the purpose at hand; for example, the display can be racic and abdominal inductance recordings. Respiratory effort
limited to EEG, electro-oculogram (EOG), and chin electro- can be assessed with respiratory inductance plethysmography,
myogram (EMG) during sleep staging and then expanded to stretch sensitive transducers (strain gauges), diaphragmatic
include respiratory and leg movement channels during scoring EMG, intrathoracic (esophageal) pressure, or nasal pressure.
of these functions. Filters and sensitivities can be altered during Scoring of sleep stages has been standardized for many years3
review to assist with interpretation of the study. and has recently been updated.4 The new scoring and staging
While digital polysomnography provides a number of criteria are discussed in detail in the text and the waveforms are
advantages as described above, features related to signal acquisi- presented in appropriate chapters.
tion, display resolution, and printer resolution must be under- As a result of these variations, the overall appearance of the
stood by the technologist and the interpreter. For digital signal polysomnographic display may be markedly different from one
acquisition, the analog signal generated by the transducer must laboratory to the next. No atlas can provide examples of nor-
be converted to digitized information. A critical variable is the mal and abnormal polysomnography using all of the displays
rate at which the signal is sampled and digitized. For slowly and transducers used in accredited sleep laboratories. For this
varying signals, such as thoracic motion, a sampling rate of atlas, the illustrations were prepared from several sleep centers
vii
FFMM..iinndddd vviiii 88//77//22000099 33::2288::0011 PPMM
viii PREFACE TO THE SECOND EDITION
and electrodiagnostic/neurophysiology laboratories in order to 3. Rechtschaffen A, Kales A. A Manual of Standardized Terminology, Tech-
introduce the reader to several of the possible formats. niques, and Scoring System for Sleep Stages of Human Subjects. Los A ngeles:
Brain Information Service/Brain Research Institute, 1968.
This atlas is designed to aid the sleep medicine specialist
4. Iber C, Ancoli-Israel S, Chesson A, Quan SF. The AASM Manual for the
and those training in sleep medicine. It also serves as a refer-
Scoring of Sleep and Associated Events: Rules, Terminology and Technical Speci-
ence and training tool for technologists. The atlas covers nor- fi cations. 1st Ed. Westchester, Illinois: American Academy of Sleep Medi-
mal polysomnographic features of wakefulness and the various cine, 2007.
stages of sleep as well as polysomnographic fi ndings character-
istic of sleep-related breathing disorders, sleep-related move-
ments, and parasomnias. In addition, examples of cardiac
arrhythmias, nocturnal seizures, and artifacts are included.
A variety of time scales are used to illustrate their value.
REFERENCES
1. American Academy of Sleep Medicine. International Classifi cation of Sleep
Disorders. 2nd Ed. Diagnostic and coding manual. Westchester, Illinois:
American Academy of Sleep Medicine, 2005.
2. Parisi RA, Santiago TV. Respiration and respiratory function: Technique
of recording and evaluation. In: Chokroverty S, ed. Sleep Disorders Medi-
cine: Basic Sciences, Technical Considerations, and Clinical Aspects. Boston:
Butterworth-Heinemann, 1994:127–139.
FFMM..iinndddd vviiiiii 88//77//22000099 33::2288::0011 PPMM
Preface to the First Edition
Sleep medicine is a relatively new medical subspecialty that is to EEG, electro-oculogram (EOG), and chin electromyogram
rapidly expanding as the prevalence and importance of sleep (EMG) during sleep staging and then expanded to include
disorders have become apparent. As with any medical disci- respiratory and leg movement channels during scoring of these
pline, accurate diagnosis is an essential prerequisite for a ratio- functions. Filters and sensitivities can be altered during review
nal approach to management. Polysomnography, the recording to assist with interpretation of the study.
of multiple physiologic functions during sleep, was developed In addition to digital polysomnography, several other tech-
in the 1970s and is the most important laboratory test used nical advances have improved the diagnostic value of sleep
in sleep medicine. Polysomnography complements the clini- recordings. Polysomnography can be combined with video
cal evaluation and assists with diagnosis and management of a recording (video-polysomnography); the simultaneous analy-
wide range of sleep disorders.1 sis of behavior and polysomnographic fi ndings assists with the
As the array of sleep diagnoses has expanded, the tech- diagnosis of parasomnias, nocturnal seizures, and other sleep-
niques and equipment used for sleep recordings have become related behaviors. To assist with the diagnosis of sleep-related
more sophisticated. While sleep studies in the 1970s used ana- breathing disorders, intrathoracic pressure can be monitored
log amplifi ers and bulky paper recordings that rarely consisted with intraesophageal pressure sensors that are easily inserted
of more than eight channels, computer technology of the late and well tolerated. With the availability of 16 to 32 or more
1990s permits recording of dozens of channels using sensitive channels for a recording, esophageal pH, end-tidal carbon diox-
noninvasive or minimally invasive transducers, digital ampli- ide level, and transcutaneous CO monitoring can be included
2
fi ers, electronic displays, and compact data storage on magnetic in selected situations without sacrifi cing standard channels.
or optical media.2 While digital polysomnography provides a number of
Digital amplifi ers and computerized signal processing pro- advantages as described above, features related to signal acquisi-
vide many advantages over older analog amplifi ers and paper tion, display resolution, and printer resolution must be under-
recording. For example, digitized data can be displayed using stood by the technologist and the interpreter. For digital signal
a compressed time scale that makes slow rhythms more read- acquisition, the analog signal generated by the transducer must
ily identifi able, such as the regular occurrence of periodic leg be converted to digitized information. A critical variable is the
movements at 20- to 30-second intervals. Alternatively, an rate at which the signal is sampled and digitized. For slowly
expanded time scale can be used that permits easier identifi ca- varying signals, such as thoracic motion, a sampling rate of 20
tion of brief electroencephalographic (EEG) transients such as Hz may be suffi cient; for rapidly varying signals, such as EEG
epileptiform sharp waves and spikes and their differentiation and EMG, the sampling rate must be much higher, usually 250
from artifacts and benign EEG waveforms. Digitized data can Hz or more. If the sampling rate is inadequate, waveforms are
also be displayed using a variety of montages depending on distorted and scoring and interpretation may be erroneous. For
the purpose at hand; for example, the display can be limited example, if the sampling rate for eye movement channels is too
ix
FFMM..iinndddd iixx 88//77//22000099 33::2288::0011 PPMM
x PREFACE TO THE FIRST EDITION
low, the sharp defl ection associated with a rapid eye movement performed in the University of Michigan Electrodiagnostic
may appear as a slower defl ection characteristic of a slow eye Laboratory. The studies were recorded using digital equipment
movement. manufactured by the Telefactor Corporation (Conshohocken,
Display resolution is based on the characteristics of the PA). The montages, fi lter settings, sensitivities, and A-D sam-
computer, the display monitor, and the software used for data pling rates used to generate the displays are specifi ed in the
acquisition and display. The array of pixels in the screen deter- Technical Introduction.
mines the maximum resolution; for example, a 1024 x 768 The illustrations were prepared based on 1600 x 1200
display provides lower resolution than a 1600 x 1200 display. screen displays and were printed with a Hewlett-Packard Laser
While the lower resolution display may be suffi cient for the Jet printer on 8.5 x 11 inch paper at 600 dot per inch resolu-
assessment of slowly varying signals such as respiration, it may tion.
be inadequate for identifi cation of rapid EEG transients. The EEG electrodes were placed according to the Interna-
Printer resolution is based on the characteristics of the tional 10–20 system.
printer, computer, and software. In some cases, waveforms that The EOG electrodes were placed 1 cm superior and lateral
are not adequately displayed on the monitor can be better ana- to the right outer canthus and 1 cm inferior and lateral to the
lyzed if a high resolution printout is obtained. left outer canthus.
Because of the differences in signal acquisition and display One chin EMG electrode was placed on the chin (mental)
parameters, not all digital recordings have the same appear- and two electrodes were placed under the chin (submental).
ance. In addition, although transducers used for the recording The submental electrode placement is generally at the mandi-
of EEG, EOG, and EMG are largely standardized, EEG and EOG ble. Generally, there is a 3-cm distance between electrodes.
montages vary among laboratories. Furthermore, transducers The EKG was recorded with one electrode each placed 2 to
and recording techniques for the assessment of respiration dur- 3 cm below the left and right clavicles midway between the
ing sleep vary widely among sleep laboratories.3 For example, shoulder and the neck..
airfl ow can be monitored directly with a pneumotachograph, Many of the recordings also include the second EKG chan-
thermistor, or thermocouple or indirectly with the recordings nel recorded from a left leg EMG channel and a left ear elec-
of tracheal sound or by the summation of signals from thoracic trode.
and abdominal inductance recordings. Respiratory effort can be Airfl ow was recorded with a single channel nasal/oral ther-
assessed with respiratory inductance plethysmography, stretch mocouple from Pro-Tech (Woodinville, WA). This thermocou-
sensitive transducers (strain gauges), diaphragmatic EMG, ple has sensors for each nostril and another that is located over
intrathoracic (esophageal) pressure, or nasal pressure. Further- the mouth.
more, although scoring of sleep stages has been standardized Thoracic and abdominal motion were recorded with respi-
for many years,4 no consensus has been reached at this writing ratory effort sensors utilizing piezoelectric crystal sensors from
concerning scoring criteria for respiratory events. EPM Systems (Midlothian, VA). These sensors are attached to a
As a result of these variations, the overall appearance of the belt that is placed around the patient.
polysomnographic display may be markedly different from For many of the recordings, an additional system was used
one laboratory to the next. No atlas can provide examples of to assess respiratory effort. This system, labeled Backup in the
normal and abnormal polysomnography using all of the dis- montages, was also recorded with piezoelectric crystal sensors
plays and transducers used in accredited sleep laboratories. For from EPM Systems (Midlothian, VA). This backup belt was
this atlas, all of the illustrations were prepared from the sleep placed between the thoracic and the abdominal belts.
studies performed at the University of Michigan Sleep Disor- Snoring sound was recorded with piezoelectric crystal sen-
ders Center, or, in a few cases, from the neonatal EEG s tudies sors from EPM Systems (Midlothian, VA). This sensor is placed
FFMM..iinndddd xx 88//77//22000099 33::2288::0011 PPMM
